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Myocardial Viability and Survival in Ischemic Left Ventricular Dysfunction Robert O. Bonow, MD On behalf of the STICH T PowerPoint Presentation
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Myocardial Viability and Survival in Ischemic Left Ventricular Dysfunction Robert O. Bonow, MD On behalf of the STICH Trial Investigators. STICH Financial Disclosures. Background.

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slide1

Myocardial Viability and Survival

in Ischemic Left Ventricular Dysfunction

Robert O. Bonow, MD

On behalf of the STICH Trial Investigators

background
Background
  • LV dysfunction in patients with CAD is not always an irreversible process, as LV function may improve substantially after CABG
  • Assessment of myocardial viability is often used to predict improvement in LV function after CABG and thus select patients for CABG
  • Numerous studies have suggested that identification of viable myocardium also predicts improved survival after CABG
limitations of cohort studies
Limitations of Cohort Studies
  • Decision for CABG may have been influenced by viability status
  • No (or inadequate) adjustment for key baseline variables (age, comorbidities)
  • Cohort studies carried out before modern aggressive medical therapy
stich revascularization hypothesis
STICH Revascularization Hypothesis
  • The first prospective randomized trial testing the hypothesis that CABG improves survival in patients with ischemic LV dysfunction compared to outcome with aggressive medical therapy
  • Provides the first opportunity to assess the interaction between myocardial viability and survival in randomized patients who were all eligible for medical management alone and also eligible for CABG.
stich viability hypothesis
STICH Viability Hypothesis
  • In this prospective substudy, we tested the hypothesis that assessment of myocardial viability identifies patients with CAD and LV dysfunction who have the greatest survival benefit with CABG compared to aggressive medical therapy
stich viability hypothesis7
STICH Viability Hypothesis
  • All randomized patients were eligible for viability testing with SPECT myocardial perfusion imaging or dobutamine echo.
  • Viability testing was optional at enrolling sites and was not a prerequisite for enrollment.
stich viability hypothesis8
STICH Viability Hypothesis
  • SPECT protocols:
  • • Thallium-201 stress-redistribution-reinjection
  • • Thallium-201 rest-redistribution
  • • Nitrate-enhanced Tc-99m perfusion imaging
  • Dobutamine echo protocols:
  • • Staged increase in dobutamine starting at
  • 5 μg/kg/min
stich viability hypothesis9
STICH Viability Hypothesis
  • Criteria for myocardial viability were prospective and pre-specified
  • SPECT:
  • 17 segment model
  • ≥11 segments manifesting viability based on relative tracer activity
  • Dobutamine echo:
  • 16 segment model
  • ≥5 segments with dysfunction at rest manifesting contractile reserve with dobutamine
stich viability hypothesis10
STICH Viability Hypothesis

Primary endpoint:

▪ All-cause mortality

Secondary endpoints:

▪ Mortality plus cardiovascular hospitalization

▪ Cardiovascular mortality

Intention-to-treat analysis

slide11

Patients randomized in STICH Revascularization Hypothesis

1212

Patients with myocardial

viability test

Patients with no myocardial viability test

594

618

Unusable test

• Timing

• Poor quality

Patients with no usable myocardial viability test

17

611

Patients with usable myocardial

viability test

601

slide12

Patients randomized in STICH Revascularization Hypothesis

1212

SPECT

n=471

Dobutamine echo

n=280

150

321

130

Patients with no usable myocardial viability test

611

Patients with usable myocardial

viability test

601

114

Nonviable

487

Viable

slide13

Baseline Characteristics

Patients With and Without Myocardial Viability

*

*

Significant covariates in risk model: Age, renal function, heart failure,

ejection fraction, CAD index, mitral regurgitation, stroke

slide14

Myocardial Viability and Mortality

1.0

Without viability

With viability

Variables associated with mortality

0.8

HR 95% CI P

0.64 0.48,0.86 0.003

0.6

Mortality Rate

50%

0.4

33%

0.2

0.0

0

1

2

3

4

5

6

Years from Randomization

Without viability

With viability

114 99 85 80 63 36 16

487 432 409 371 294 188 102

slide16

Myocardial Viability and Cardiovascular Mortality

1.0

Without viability

With viability

0.8

HR 95% CI P

0.61 0.44,0.84 0.003

0.6

43%

Cardiovascular Mortality Rate

0.4

29%

0.2

0.0

0

1

2

3

4

5

6

Years from Randomization

Without viability

With viability

114 99 85 80 63 36 16

487 432 409 371 294 188 102

slide17

Myocardial Viability and Mortality + CV Hospitalization

1.0

Without viability

With viability

82%

0.8

HR 95% CI P

0.59 0.47,0.74 0.001

0.6

63%

Mortality and CV Hospitalization Rate

0.4

HR 95% CI P

0.59 0.47,0.44 <0.001

0.2

0.0

0

1

2

3

4

5

6

Years from Randomization

Without viability

With viability

114 56 41 34 22 14 5

487 327 284 238 166 94 41

slide18

Patients with

viability tests

601

Patients with myocardial viability

487

114

Patients without myocardial viability

243

244

60

54

CABG

47.4%

MED

49.9%

CABG

50.1%

MED

52.6%

slide19

Baseline Characteristics

*

*

*

Significant covariates in risk model: Age, renal function,

heart failure, ejection fraction, CAD index, MR, stroke

slide20

Myocardial Viability and Mortality

Without Viability

With Viability

1.0

MED (95 deaths)

CABG (83 deaths)

MED (33 deaths)

CABG (25 deaths)

0.8

56%

0.6

Mortality Rate

35%

0.4

42%

31%

0.2

0.0

0

1

2

3

4

5

6

0

1

2

3

4

5

6

Years from Randomization

Years from Randomization

MED

CABG

60 51 44 39 29 14 4 243 219 206 179 146 94 51

54 48 41 41 34 22 12 244 213 203 192 148 94 51

slide21

Myocardial Viability and Mortality

Without Viability

With Viability

1.0

MED (95 deaths)

CABG (83 deaths)

MED (33 deaths)

CABG (25 deaths)

0.8

56%

0.6

Mortality Rate

35%

0.4

42%

31%

0.2

0.0

0

1

2

3

4

5

6

0

1

2

3

4

5

6

Years from Randomization

Years from Randomization

Subgroup

Without viability

With viability

N Deaths HR 95% CI

114 58 0.70 0.41, 1.18

487 178 0.86 0.64, 1.16

Interaction

P value

0.528

0.25

0.5

1

2

CABG

better

MED

better

stich viability hypothesis23
STICH Viability Hypothesis

Limitations:

  • Lack of viability data in all patients; patients represent a subpopulation of STICH
  • Analysis limited to SPECT and dobutamine echo, not PET or cardiac MRI
stich viability hypothesis24
STICH Viability Hypothesis
  • STICH represents the largest report to date relating myocardial viability to clinical outcomes of patients with CAD and LV dysfunction
  • … and is the first to assess these relationships prospectively among patients who were all eligible for CABG as well as optimal medical management alone
stich viability hypothesis25
STICH Viability Hypothesis

STICH results:

  • …demonstrate a significant association between myocardial viability and outcome, but this association is rendered non-significant when subjected to a multivariable analysis that includes other prognostic variables.
  • …fail to demonstrate a significant interaction between myocardial viability and medical versus surgical treatment with respect to mortality, whether assessed according to treatment assigned (intention to treat) or to the treatment actually received.
stich viability hypothesis26
STICH Viability Hypothesis
  • Implications:
  • In patients with CAD and LV dysfunction, assessment of myocardial viability does not identify patients who will have the greatest survival benefit from adding CABG to aggressive medical therapy

Full report available at www.NEJM.org